Clinical Documentation Nurse - Full Time - Ephrata

Ephrata, PA | Nursing | Tracking Code: 63481

Job Description:

Under the general supervision of the Manager-Clinical Documentation Improvement, reviews medical record documentation to facilitate the accurate representation of the severity of illness, patient acuity and risk of mortality for a specified patient population. Obtains appropriate clinical documentation through extensive interaction with physicians, healthcare providers and Health Information Management (HIM) professionals. Actively participate in meetings and education of staff related to Clinical Documentation Improvement (CDI).


Duties and Responsibilities

Essential Accountabilities:

  1. Facilitates CDI education to physicians and clinicians by creating timely presentations that can be shared by Clinical Documentation Nurse (CDRN) staff, while minimizing the non-productive time of the team.
  2. Audits CDRN reviews for quality and compliance and validates queries for consistency and impact. Shares findings with Supervisor and Manager.
  3. Reviews and updates policies and procedures.
  4. Evaluates daily census in CDI software to identify need for facility cross coverage.
  5. Serves as a subject matter expert for the CDI team and supports new hires after the orientation period. Provides orientation in the absence of the Supervisor.
  6. Completes four items noted in the internal policy to demonstrate advanced CDI practice and employee engagement.
  7. Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients by completing accurate and timely record reviews.
  8. Improves the overall quality and completeness of clinical documentation by performing admission and continued stay reviews.
  9. Demonstrates knowledge of Diagnosis Related Group (DRG) payer issues, documentation opportunities, and clinical documentation requirements.
  10. Demonstrates knowledge of Medicare, general understanding of hospital based quality initiatives, and regulatory environment.
  11. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
  12. Completes timely follow up on all cases, especially those with clinical documentation clarifications and ensures points of clarification have been recorded in the patients’ medical record.
  13. Formulates ethical and clinically credible documentation clarifications.
  14. Processes discharges by updating the CDI software to reflect any changes in status, procedures and treatments, and confers with clinicians to finalize diagnoses.
  15. Accurately inputs data into the CDI software.
  16. Effectively and appropriately communicates with physicians and healthcare providers.
  17. Reviews clinical issues with coding staff to assign a working DRG and reconcile final DRG.
  18. Serves as a member of the CDI Task Force.
  19. Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
  20. Prepares educational materials for presentation at meetings, physician grand rounds, interdisciplinary rounds, physician staff meetings, and participates in new provider orientations.

NonEssential Accountabilities:

  1. Prepares and presents data analysis as required.
  2. Assists with special projects and attends meetings as needed.
  3. Performs other related duties as identified.

Common Expectations:

  1. Prepares and maintains appropriate documentation as required.
  2. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
  3. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovationThe following are nonessential job accountabilities for purposes:


  • Notes:
    • Other combinations of formal education, training and experience may be considered.
  • Minimum Experience:
    • 2 years CDI experience with certification in specialty; 5 years recent acute care with ICU experience; Case management preferred
    • Min Field of ExpertiseClinical Documentation Nurse I for internal applicants
    • Req Cert/RegistrationRegistration and current RN license in PA; Certification in Clinical Documentation Improvement
  • Minimum Education:
    • Bachelor’s Degree
  • Physical Demands:
    • Mostly sedentary work
    • Occasional prolonged standing/walking
  • Skills:
    • OtherOrganized, analytical, self-directed with critical thinking, problem solving and deductive reasoning skills; computer skills; experience with PowerPoint, Excel and Microsoft Office
    • The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
Similar Opportunities

Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Lancaster City was the capital of Pennsylvania from 1799 to 1812. Today, Lancaster County includes a vibrant downtown business district, desirable suburban neighborhoods and sprawling agricultural farms. Life in Lancaster County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, an independent professional baseball team, fine dining and more. When visiting Lancaster, one can't help but recognizing the influence of the Pennsylvania Dutch — farm-to-table and beyond.

Conveniently located in southcentral Pennsylvania, Lancaster is within an easy commute to major cities and has ready access to public transportation. Residents can find local employment in healthcare, tourism, public administration, manufacturing, and both professional and semi-professional services. (Patient population: 535,000)